Prevention is key
Improving prevention is the obvious priority for healthcare systems. If confronted with a healthcare-system genie, surely your first, albeit glib, wish would be 'no more sickness'. In wishing for this, you would identify the holy grail of ‘primary’ prevention (actions that prevent illnesses occurring in the first place). The recently announced ‘healthy food standard’, requiring retailers to find ways of getting people to purchase healthier foods to tackle the obesity epidemic, is an archetypal example.
In reality, however, not all diseases can be prevented in this way; prevention needs to be baked into the entire healthcare system. That is why ‘secondary’ prevention (detecting and identifying a disease early to be able to intervene quickly and prevent it worsening) and ‘tertiary’ prevention (managing a developed disease to slow progression and reduce the impact of symptoms) measures are vital to enabling people to stay healthy, improve quality of life and reduce cost and demand to health systems.
It makes sense, then, that one of the three ‘shifts’ that provide the framework and underpinning of the Government’s 10-Year Health Plan to create an NHS ‘fit for the future’ is ‘sickness to prevention’. However, for this to be successful, fundamental healthcare system reform is needed which requires carefully placed (but substantial) initial investment.
Prevention is hard but worth it
The simplicity of the principle belies the scale of the challenge of delivering a prevention-focused healthcare system. Even before the pandemic, the number of people living with multiple chronic conditions was growing by over eight percent a year. Without a fundamental change in approach the pressure on the healthcare system will worsen. At the current rate it is predicted that, by 2040, nearly 25 percent more working age adults will have a diagnosed major illness.
The personal health and healthcare system benefits lead to economic benefits. Not only are primary, secondary, and tertiary prevention efforts cost effective for the healthcare system, treasury estimates suggest that a one percent increase in the number of people aged 50-64 in work would increase GDP by around £5.7 billion a year. This is not surprising: simple behavioural changes and diagnostic interventions early avoid major surgical interventions or medicines spends later in life and keep people healthy for longer.
What is surprising is our persistent perception of prevention measures as ‘cost’ and our reticence to invest in them. Reports from those who have seen an early version of the 10-Year Health Plan suggest that additional spend on prevention might be deprioritised – the focus still being on elective targets – and the more radical proposed changes, including increasing the spending in primary and community care, will only kick in towards the back end of the plan. This is not a new phenomenon. Previous administrations have committed to prioritising prevention but the long-term nature of such a project makes governments, ultimately concerned with demonstrating impact in a five-year election cycle, baulk at the required investment.
Unless this changes, the Government’s ‘prevention focus’ will only be lip service to this well-established need. I want to see investment in two healthcare system paradigm shifts that will be essential for effectively preventing illness.
Prevention requires…a data and digital overhaul
First, the core digital structures and capabilities of the NHS need a major tune-up. Effective prevention requires the whole healthcare system knowing what other parts are up to / what care it is administering to which patient. This requires the efficient and rapid collection and sharing of patient data.
And yet, the NHS’s digital system lacks interoperability, due to siloed third-party data providers, geographical disparities in NHS App usage, and ongoing use of paper (71 percent of trusts in the UK use paper in some form, despite having electronic patient records). Without interoperability, the healthcare system, especially primary care settings, cannot have total visibility of a patient’s care and will miss vital opportunities to make preventative interventions.
The Government also is at risk of ‘running before it can walk’ with prevention-focused digitalisation. Hospitals are already using AI tools to diagnose cancer faster or assist hospital managers and the 171 million-pound ‘Fit-for-the-Future’ fund aims to facilitate the adoption of AI-equipped CT and MRI scanners to speed up diagnosis and treatment. All of these tools, however, require analysis of large patient data sets and capable IT systems. There will be no point in committing spending on flashy digital technology to drive prevention if the underpinning infrastructure is missing.
To build a sustainable prevention model, major investment (estimated to be around £21 billion) is needed in basic data and digital infrastructure. This includes creating centralised data collection and audit services, such as CVDPREVENT, which improve the quality of care and reduce inequalities across the healthcare system and structures that enable NHS and third-party suppliers and providers to work together.
Prevention requires…better integration of independent sector capacity and innovation
Second, the Government should consider how to better integrate and collaborate with the independent healthcare sector to deliver primary and secondary prevention. NHS patients in private healthcare settings are treated on average 7 weeks earlier than in NHS settings. Private providers are also offering ‘doctor-on-demand’ primary care services and deploying at-home genetic bladder cancer tests. The capacity and innovation in the independent sector significantly improves the speed and access to diagnosis and treatment interventions and, if working with the NHS, these privately provided services can easily be rolled-out across the population where they are most needed.
Employer-provided health insurance could even be regarded as an early form of primary prevention. Workplace schemes can offer same-day appointment subscription services, occupational therapy, and joint pain programmes. These give access to preventative care or encourage preventive behaviours as a routine part of life and reduce the number of people entering the NHS, significantly relieving pressure on the healthcare system.
The Government need to seriously consider how to make the private sector a prevention asset. This will require an ideological shift from viewing the use of the independent sector as ‘selling out’ to it being a valuable means-to-an-end for better population health. It will also require better integration of private providers in healthcare system structures, like Integrated Care Systems, and fiscal changes to incentivise employers to provide preventive healthcare services.
The integration of the independent sector into the NHS is an urgent priority. The individual insurance market has been growing over 10 percent annually for the last few years and so Government need to take the opportunity with the 10-Year Health Plan to ensure that prevention does not become a two-tier privilege, only for those are personally, or through their employment, able to access private healthcare.
A healthcare system that is dedicated to prevention is essential for a healthy population and a well-functioning NHS. However, this requires a willingness to lay the right foundations and invest in the fundamental reform that will see the most improvement in the prevention of sickness. The 10-Year Plan needs to face this difficult truth, shirk the constraints of precedence, not be distracted by the excitement of short-term fixes and truly be future-focused.